- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,765.33 / $13,059.90 / $13,059.90
| Professional | | $3,765.33 | $13,059.90 | $13,059.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,717.61 / $5,180.63 / $5,180.63
| Facility | | $2,717.61 | $5,180.63 | $5,180.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,717.61 / $4,212.93 / $5,180.63
| Professional | | $2,717.61 | $4,212.93 | $5,180.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,063.09 / $4,933.93 / $5,180.63
| Facility | | $2,063.09 | $4,933.93 | $5,180.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,717.61 / $3,888.29 / $5,184.38
| Professional | | $2,717.61 | $3,888.29 | $5,184.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,668.55 / $1,846.11 / $3,076.85
| Professional | | $1,668.55 | $1,846.11 | $3,076.85 |